Ramin Fathi

Genital warts and other HPV infections: Established and novel therapies

Wart therapies involve methods of targeted lesion destruction, as well as selective immunologic modification. While there are several therapeutic options, no treatment has been proven to be superior in terms of clinical clearance or recurrence. Controlled trials comparing treatments are currently lacking. Many factors are used in the selection of treatment. Variables that should be taken into account include but are not limited to the morphology of the lesions such as thickness and size, quantity, anatomic location, human papilloma virus (HPV) classification, immunocompromized or immune competent status, as well as the preferences of the patient and the provider, cost and availability. No current treatment completely eradicates the human papillomavirus virus. The availability of vaccinations against HPV infection is contributing to the decreasing incidence of this disease. This contribution highlights conventional therapies, off-label treatment strategies including combination therapies, and prophylaxis for condylomata acuminata.

The Role of Biologic Therapies in Dermatology

Biologic therapy has dramatically changed the way medicine, and specifically dermatology, is practiced today. The use of biologic agents in dermatology is evolving, with psoriasis being the most common indication for which biologics are used currently. However, several other dermatologic diseases seem to be responsive to biologic therapy, and continuing research and development efforts are elucidating the benefit-risk profiles of various biologic medications in these dermatologic conditions. Although biologic agents have revolutionized the management of dermatologic conditions, cost must also be considered when evaluating management options, especially compared with traditional agents. For example, the cost of 1 year of induction and maintenance treatment of psoriasis in 2014 was estimated to be

Identifying and Managing Local Anesthetic Allergy in Dermatologic Surgery.

53,909 for ustekinumab,

A Novel Treatment Approach for Extensive, Eruptive, Cutaneous Squamous Cell Carcinomas in a Patient Receiving BRAF Inhibitor Therapy for Metastatic Melanoma

46,395 for etanercept, and

Minimally invasive eyelid care in dermatology: medical, laser, and cosmetic therapies.

39,041 for adalimumab. Nonetheless, because of their efficacy, the cost of a biologic may be offset by significant reductions in the number of hospital stays, reduction in use of other systemic therapies, and increased satisfaction by patients.32 Thus, understanding their mechanisms of action, labeled and off-label uses in dermatology, and common adverse effects helps to inform clinical decision making and improve patient outcomes.

Inaccuracies in SEER registry data on melanoma thickness

BACKGROUND Local anesthetic (LA) allergy is a concern for dermatologic surgeons given the large number of procedures performed yearly with LAs. Many patients also have anxiety about past or potential anesthesia allergy. OBJECTIVE This article will review the symptoms of IgE-mediated allergic reactions, the prevalence of IgE-mediated LA allergy, discuss common mimics of LA, and propose a practical approach for diagnostic and therapeutic options for LA allergy for the dermatologic surgeon in practice. MATERIALS AND METHODS A literature search of Pubmed using keywords “lidocaine,” “local anesthetic,” “hypersensitivity,” and “allergy” was performed. RESULTS Amide anesthetics result in the most reports of true local anesthetic immediate hypersensitivity. CONCLUSION True IgE-mediated anaphylaxis to local anesthesia is very rare. Dermatologic surgeons should be aware of the symptoms of anesthetic allergy and its mimickers, as well as how to manage allergic reactions in their clinical practice.

Undermining and Hemostasis.

Vemurafenib is a potent inhibitor of BRAF with the V600E mutation and is approved for advanced cases of metastatic melanoma. Squamous cell carcinoma (SCC) has been described in patients receiving higher dosages. We present a case of a metastatic melanoma survivor who has developed 58 eruptive SCCs while taking vemurafenib that were successfully treated using an aggressive surgical and immunomodulatory approach using a combination of Mohs micrographic and excisional surgery, modified photodynamic therapy (PDT), and 5-fluorouracil (FU).

Performance of a computer-aided digital dermoscopic image analyzer for melanoma detection in 1,076 pigmented skin lesion biopsies

There is a high demand for facial aesthetic enhancement, and the periorbital region is one of the first areas to show signs of aging. Many nonsurgical therapies exist to tackle these problems. These therapies are becoming more efficacious while reducing postprocedural recovery time. The goal is to restore the natural youthful appearance rather than to create an effect that differs from the patients appearance earlier in life. Eyelid care, and cosmetic dermatology in general, intends to restore balance and symmetry. We discuss the initial consultation, relevant anatomy for the dermatologist, and medical, laser and cosmetic therapies.

A hyperpigmented rash on face and chest

To the Editor: We very much enjoyed reading the recent study by Landow et al on the prognosis of melanomas on the basis of their thickness. The data were expertly analyzed and unveiled a fascinating finding that ultrathin melanomas with a thickness of 0.01 to 0.25 mm carried a higher risk of death than melanomas with a thickness of 0.26 to 0.50 mm. Indeed, this finding is counterintuitive to the field’s understanding of melanoma—the earlier that melanoma is detected, the thinner it should be and the greater the likelihood of patient survival. Landow et al propose several unrecorded variables that could explain this unexpected finding: mitoses, lymphovascular invasion, regression, and genetic mutations. Other studies of SEER (Surveillance, Epidemiology, and End Results) melanoma data have also uncovered unexpected findings. For example, Bagaria et al found that the thinnest melanomas (#0.50 mm) with lymph node involvement had a worse prognosis than did thicker melanomas (up to 2 mm) with lymph node involvement. Although unaccounted variables may provide part of the explanation regarding the above findings, it is possible that there is something unique about the SEER data set that is causing the unexpected results. To this end, we would like to highlight a recent study by Gimotty et al that investigated this issue. They investigated mortality in relation to melanoma thickness in the SEER registry, and they compared it with similar data from other cohorts in the United States and other countries. They found that the 5-year cumulative melanoma-related death rate of patients with ultrathin melanomas (#0.25 mm) was significantly higher in SEER (2.8%) than in the other registries (0.6-0.9%). To further investigate this discrepancy, they re-examined the inputted thickness data and the accompanying pathology reports from one SEER site. They found that more than a quarter of the ultrathin melanomas had errors in the recording of their thickness. Most of these errors were due to decimal point misplacement, and most of the thicknesses were off by a factor of 10 or higher. After correcting the data, only 4% of deaths originally attributed to ultrathin melanomas remained for this SEER site. Also, none of the remaining patients with ultrathin melanomas had positive lymph node biopsy results.

Current perspectives on Mohs micrographic surgery for melanoma

BACKGROUND Undermining and hemostasis are basic surgical techniques that can have a significant impact on surgical outcomes. OBJECTIVE To review the mechanisms and techniques of undermining and hemostasis, with an emphasis on the advantages and limitations of each modality. MATERIALS AND METHODS The PubMed database was searched for articles with the keywords “undermining,” “hemostasis,” and “electrosurgery.” RESULTS Whether performing blunt, sharp, or electrosurgical techniques, undermining at the appropriate depth and width is necessary for tissue movement during closures. Both excessive and inadequate undermining can compromise surgical healing. Surgical hemostasis techniques include pressure, suture ligation, topical hemostatic agents, and electrosurgery. Dermatologic surgeons should select the appropriate amount and type of hemostasis for each procedure. Particular care should be taken in performing electrosurgery, given the potential for complications. CONCLUSION Understanding and optimizing hemostasis and undermining will allow dermatologic surgeons to execute complex closures with minimal complications.